Developing and validating the Unhurried Conversations Assessment Tool (UCAT)

OBJECTIVE

Given the importance of unhurried conversations for providing careful and kind care, we sought to create, test, and validate the Unhurried Conversations Assessment Tool (UCAT) for assessing the unhurriedness of patient-clinician consultations.

METHODS

In the first two phases, the unhurried conversation dimensions were identified and transformed into an assessment tool. In the third phase, two independent raters used UCAT to evaluate the unhurriedness of 100 randomly selected consultations from 184 videos recorded for a large research trial. UCAT's psychometric properties were evaluated using this data.

RESULTS

UCAT demonstrates content validity based on the literature and expert review. EFA and reliability analyses confirm its construct validity and internal consistency. The seven formative dimensions account for 89.93% of the variance in unhurriedness, each displaying excellent internal consistency (α > 0.90). Inter-rater agreement for the overall assessment item was fair (ICC = 0.59), with individual dimension ICCs ranging from 0.26 (poor) to 0.95 (excellent).

CONCLUSION

UCAT components comprehensively assess the unhurriedness of consultations. The tool exhibits content and construct validity and can be used reliably.

PRACTICE IMPLICATIONS

UCAT's design and psychometric properties make it a practical and efficient tool. Clinicians can use it for self-evaluations and training to foster unhurried conversations.

Paging Dr. Google: Characterizing Direct to Consumer Internet Advertisements from Oncology Treatment Centers

PURPOSE/OBJECTIVE(S)

Patients increasingly use internet searches to compare treatment options and decide on oncology treatment centers. The objective of this study is to examine the type of oncology treatment centers that were advertised on web-based searches.

MATERIALS/METHODS

A series of keyword searches were conducted using the Google search engine. Based on search trends, 3 of the top relevant search phrases were used ("best cancer doctor", "best cancer treatment", and "cancer treatment near me"). Modifiers were added to each search term to reflect the cancer categories with the highest prevalence: "breast", "prostate", and "lung". This yielded 12 search phrases that were used on a search hub that simulates Google searches from different geographic locations. The 30 most populous city locations were used. Of the four paid advertisements at the top of each search, the cancer treatment centers were categorized into centers that are National Cancer Institute-Designated (NCIs), Commission on Cancer (CoC) accredited, non-CoC accredited, and non-traditional treatment centers. Advertisements that weren't for cancer treatment centers were excluded.

RESULTS

Of the 360 searches and 817 subsequent cancer treatment center advertisements, 51.2% were for NCI, 12.2% were CoC accredited, 26.9% were non-CoC accredited, and 9.7% were non-traditional treatment centers. The search phrase that yielded the highest ratio of NCI results was "best cancer doctor" at 74.4% and the phrase that yielded the lowest was "prostate cancer treatment near me" at 37.1%. Of the known 71 NCI centers in the country, 42 (59.2%) did not have any advertisements. Of the 35 NCI centers located in one of the target cities, 12 (34.3%) did not have any advertisements. Notably, two specific NCI centers accounted for 49.5% of the NCI advertisements. Similarly, one specific non-traditional treatment center accounted for 48.1% of the non-traditional center advertisements. Regarding non-traditional treatment centers, there was geographic variation with Boston having 38.1% of searches yielding non-traditional treatment center advertisements as opposed to six cities having 0%. The ratio of non-traditional treatment center advertisements by region were as follows: Northeast with 13.6%, West with 12.6%, South with 7.7%, and Midwest with 5.0%.

CONCLUSION

These results indicate that most direct-to-consumer cancer advertisements come from CoC or NCI centers. Among advertisements coming from NCI centers, relatively few centers account for the majority of advertisements with most NCI centers having no advertising presence. Future research is needed to evaluate claims, costs, and the ethical considerations of direct-to-consumer marketing, where the potential for mischaracterizing the strength of the scientific evidence to vulnerable cancer populations requires more scrutiny.

Delay in Time to Oncologic Therapies for Patients with Positive COVID-19 Test

PURPOSE/OBJECTIVE(S)

For several cancers, delays between diagnosis and initiation of treatment has important clinical implications, often affecting trial eligibility, treatment intention, and oncologic outcomes. The coronavirus disease-19 (COVID-19) pandemic placed an extraordinary strain on the United States healthcare system, and its effect on oncologic patterns of care has yet to be established. We hypothesize that patients who received a new cancer diagnosis and subsequently tested positive for COVID-19 had delayed oncologic treatment compared to those who did not test positive for COVID-19.

MATERIALS/METHODS

The National Cancer Database (NCDB) was queried to identify patients who were diagnosed and treated for any of 10 common malignancies from 2019-2020. Included disease sites were head and neck, esophagus, rectum, anus, lung, breast, cervix, uterus, prostate, and primary brain. Those who tested positive for COVID-19 between time of diagnosis and first oncologic treatment (including surgery, radiation, or systemic therapy) were compared to those who did not test positive for COVID-19. COVID-19 positivity was assessed using a new variable in the NCDB, "SARSCOV2_POS," which captures whether patients received a positive COVID-19 test via reverse transcriptase-polymerase chain reaction testing in inpatient, outpatient, or emergency room settings in 2020. Duration in days from cancer diagnosis to time to first treatment (TTFT) was analyzed using two-sample t-tests, with significance level of p<0.05.

RESULTS

A total of 1,503,127 patients were identified for analysis. Of these, 7,340 (0.5%) tested positive for COVID-19 between diagnosis and start of treatment. Initial treatment was most commonly surgery (55.3%), followed by systemic therapy (17.4%) and radiation (12.7%). Overall, median TTFT was 55 days [interquartile range (IQR) 31-91] for the COVID-19 group versus 34 days (IQR 15-56) for the non-COVID-19 group (p <0.01). Subgroup analysis of the 10 individual sites of disease revealed statistically significant delays in each, with greatest absolute difference in median TTFT in prostate (31.5 days; 95.5 versus 64.0) and greatest relative difference in brain (>700%, 28.5 versus 4.0).

CONCLUSION

In the first year of the pandemic, patients who tested positive for COVID-19 between oncologic diagnosis and initial management experienced significant delays in initiation of cancer-directed therapy compared to those who did not test positive for COVID-19, with median increase in TTFT of 21 days. Additional follow-up is needed to evaluate the clinical impact of these delays, as well as change in patterns of care in later years of the pandemic.

Diverse clonal fates emerge upon drug treatment of homogeneous cancer cells

Even among genetically identical cancer cells, resistance to therapy frequently emerges from a small subset of those cells1-7. Molecular differences in rare individual cells in the initial population enable certain cells to become resistant to therapy7-9; however, comparatively little is known about the variability in the resistance outcomes. Here we develop and apply FateMap, a framework that combines DNA barcoding with single-cell RNA sequencing, to reveal the fates of hundreds of thousands of clones exposed to anti-cancer therapies. We show that resistant clones emerging from single-cell-derived cancer cells adopt molecularly, morphologically and functionally distinct resistant types. These resistant types are largely predetermined by molecular differences between cells before drug addition and not by extrinsic factors. Changes in the dose and type of drug can switch the resistant type of an initial cell, resulting in the generation and elimination of certain resistant types. Samples from patients show evidence for the existence of these resistant types in a clinical context. We observed diversity in resistant types across several single-cell-derived cancer cell lines and cell types treated with a variety of drugs. The diversity of resistant types as a result of the variability in intrinsic cell states may be a generic feature of responses to external cues.

Targeting PD-L2-RGMb overcomes microbiome-related immunotherapy resistance

The gut microbiota is a crucial regulator of anti-tumour immunity during immune checkpoint inhibitor therapy. Several bacteria that promote an anti-tumour response to immune checkpoint inhibitors have been identified in mice1-6. Moreover, transplantation of faecal specimens from responders can improve the efficacy of anti-PD-1 therapy in patients with melanoma7,8. However, the increased efficacy from faecal transplants is variable and how gut bacteria promote anti-tumour immunity remains unclear. Here we show that the gut microbiome downregulates PD-L2 expression and its binding partner repulsive guidance molecule b (RGMb) to promote anti-tumour immunity and identify bacterial species that mediate this effect. PD-L1 and PD-L2 share PD-1 as a binding partner, but PD-L2 can also bind RGMb. We demonstrate that blockade of PD-L2-RGMb interactions can overcome microbiome-dependent resistance to PD-1 pathway inhibitors. Antibody-mediated blockade of the PD-L2-RGMb pathway or conditional deletion of RGMb in T cells combined with an anti-PD-1 or anti-PD-L1 antibody promotes anti-tumour responses in multiple mouse tumour models that do not respond to anti-PD-1 or anti-PD-L1 alone (germ-free mice, antibiotic-treated mice and even mice colonized with stool samples from a patient who did not respond to treatment). These studies identify downregulation of the PD-L2-RGMb pathway as a specific mechanism by which the gut microbiota can promote responses to PD-1 checkpoint blockade. The results also define a potentially effective immunological strategy for treating patients who do not respond to PD-1 cancer immunotherapy.

Intestinal toxicity to CTLA-4 blockade driven by IL-6 and myeloid infiltration

Immune checkpoint blockade (ICB) has revolutionized cancer treatment, yet quality of life and continuation of therapy can be constrained by immune-related adverse events (irAEs). Limited understanding of irAE mechanisms hampers development of approaches to mitigate their damage. To address this, we examined whether mice gained sensitivity to anti-CTLA-4 (αCTLA-4)-mediated toxicity upon disruption of gut homeostatic immunity. We found αCTLA-4 drove increased inflammation and colonic tissue damage in mice with genetic predisposition to intestinal inflammation, acute gastrointestinal infection, transplantation with a dysbiotic fecal microbiome, or dextran sodium sulfate administration. We identified an immune signature of αCTLA-4-mediated irAEs, including colonic neutrophil accumulation and systemic interleukin-6 (IL-6) release. IL-6 blockade combined with antibiotic treatment reduced intestinal damage and improved αCTLA-4 therapeutic efficacy in inflammation-prone mice. Intestinal immune signatures were validated in biopsies from patients with ICB colitis. Our work provides new preclinical models of αCTLA-4 intestinal irAEs, mechanistic insights into irAE development, and potential approaches to enhance ICB efficacy while mitigating irAEs.

Abstract 5545: Intestinal toxicity to CTLA-4 blockade driven by IL-6 and myeloid infiltration

Immunotherapies such as anti-CTLA-4 immune checkpoint blockade (ICB) have revolutionized cancer treatment, yet quality of life and continuation of therapy can be constrained by off-target tissue damage or immune-related adverse events (irAEs). At present, there is limited understanding of irAE mechanisms, hampering development of approaches to mitigate their damage. We addressed this problem by generating animal models of intestinal irAE. Our results show that disruption of homeostatic immunity by genetic predisposition to intestinal inflammation or acute gastrointestinal infection sensitizes mice to anti-CTLA-4-mediated intestinal toxicity. Inflammation-prone mice treated with anti-CTLA-4 showed neutrophil accumulation, systemic interleukin-6 (IL-6) release, and dysbiosis. Significantly, IL-6 blockade combined with antibiotic treatment improved anti-CTLA-4 therapeutic efficacy and reduced intestinal irAEs. Immune signatures were validated in biopsies from patients who developed colitis during ICB, supporting the utility of our models. This study provides new pre-clinical models, mechanistic insight into irAEs, and potential approaches to enhance ICB efficacy while mitigating irAEs.

Citation Format: Yifan Zhou, Yusra B. Medik, Bhakti Patel, Daniel B. Zamler, Sijie Chen, Thomas Chapman, Sarah Schneider, Rachel L. Babcock, Taylor T. Chrisikos, Laura M. Kahn, Allison M. Dyevoich, Elizabeth M. Park, Alexandria P. Cogdill, Daniel H. Johnson, Sarah B. Johnson, Khalida M. Wani, Debora A. Ledesma, Courtney W. Hudgens, Jingjing Wang, Md Abdul Wadud Khan, Aron Y. Joon, Weiyi Peng, Haiyan S. Li, Reetakshi Arora, Ximing Tang, Maria Gabriela Raso, Xuegong Zhang, Wai Chin Foo, Michael T. Tetzlaff, Gretchen E. Diehl, Karen Clise-Dwyer, Elizabeth M. Whitley, Matthew M. Gubin, James P. Allison, Patrick Hwu, Nadim J. Ajami, Adi Diab, Jennifer A. Wargo, Stephanie S. Watowich. Intestinal toxicity to CTLA-4 blockade driven by IL-6 and myeloid infiltration [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5545.

Ethical Reasoning During a Pandemic: Results of a Five Country European Study

Introduction: There has been no work that identifies the hidden or implicit normative assumptions on which participants base their views during the COVID-19 pandemic, and their reasoning and how they reach moral or ethical judgements. Our analysis focused on participants' moral values, ethical reasoning and normative positions around the transmission of SARS-CoV-2.Methods: We analyzed data from 177 semi-structured interviews across five European countries (Germany, Ireland, Italy, Switzerland and the United Kingdom) conducted in April 2020.Results: Findings are structured in four themes: ethical contention in the context of normative uncertainty; patterns of ethical deliberation when contemplating restrictions and measures to reduce viral transmission; moral judgements regarding "good" and "bad" people; using existing structures of meaning for moral reasoning and ethical judgement.Discussion: Moral tools are an integral part of people's reaction to and experience of a pandemic. 'Moral preparedness' for the next phases of this pandemic and for future pandemics will require an understanding of the moral values and normative concepts citizens use in their own decision-making. Three important elements of this preparedness are: conceptual clarity over what responsibility or respect mean in practice; better understanding of collective mindsets and how to encourage them; and a situated, rather than universalist, approach to the development of normative standards.

Abstract P018: Gut microbiota-driven alterations in tumor immunity can modulate the growth of metastatic brain tumors

Background: Metastatic brain tumors are associated with significant morbidity and mortality. The current limited understanding of the mechanisms underlying brain metastasis has hindered the development of efficient diagnostics and therapeutics for this disease. Microbiota has emerged as a novel hallmark of cancer, with a prominent role in tumorigenesis, tumor immunity, and response to treatment. However, the role of the microbiota in tumor metastasis, and in particular brain metastasis, is poorly understood. We hypothesize that distinct microbial communities can alter the immune microenvironment in the brain and modulate the different steps of brain metastasis formation.

Methods: To explore the role of gut microbiota in brain metastasis, we depleted gut microbiota in conventionally raised mice using a broad-spectrum non-absorbable antibiotic regimen. Subsequently, melanoma tumor cells were injected intracranially to evaluate the effect of gut microbiota depletion and associated immune changes on tumor growth. Tumor growth was measured through in vivo bioluminescent imaging and histology. Peripheral and tumor immune profiling was conducted through flow cytometry and immunohistochemistry.

Results: Depletion of the gut microbiota in mice decreased tumor growth in the brain. Evaluation of the peripheral and tumor immune profiles suggested the underlying mechanisms to involve alterations in the circulating cytokine profiles and an increase in anti-tumor T cell activity.

Conclusion: Our clinical studies suggest the association of distinct microbial communities with brain metastasis. Our pre-clinical findings demonstrate that the absence of gut microbiota can modulate the regulation of T cell activity to induce an anti-tumor response in the brain. Further studies, currently in progress, will determine the mechanistic role of dysbiotic microbiota and distinct microbial communities in this process.

Citation Format: Golnaz Morad, Sarah B. Johnson, Jennifer A. Wargo. Gut microbiota-driven alterations in tumor immunity can modulate the growth of metastatic brain tumors [abstract]. In: Abstracts: AACR Virtual Special Conference: Tumor Immunology and Immunotherapy; 2021 Oct 5-6. Philadelphia (PA): AACR; Cancer Immunol Res 2022;10(1 Suppl):Abstract nr P018.

Microbiota triggers STING-type I IFN-dependent monocyte reprogramming of the tumor microenvironment

The tumor microenvironment (TME) influences cancer progression and therapy response. Therefore, understanding what regulates the TME immune compartment is vital. Here we show that microbiota signals program mononuclear phagocytes in the TME toward immunostimulatory monocytes and dendritic cells (DCs). Single-cell RNA sequencing revealed that absence of microbiota skews the TME toward pro-tumorigenic macrophages. Mechanistically, we show that microbiota-derived stimulator of interferon genes (STING) agonists induce type I interferon (IFN-I) production by intratumoral monocytes to regulate macrophage polarization and natural killer (NK) cell-DC crosstalk. Microbiota modulation with a high-fiber diet triggered the intratumoral IFN-I-NK cell-DC axis and improved the efficacy of immune checkpoint blockade (ICB). We validated our findings in individuals with melanoma treated with ICB and showed that the predicted intratumoral IFN-I and immune compositional differences between responder and non-responder individuals can be transferred by fecal microbiota transplantation. Our study uncovers a mechanistic link between the microbiota and the innate TME that can be harnessed to improve cancer therapies.

Stakeholder perspectives of pediatric powered wheelchair standing devices: a qualitative study

AIM

To explore and describe the experiences and perspectives of various stakeholders regarding the use of powered wheelchair standing devices (PWSDs).

METHOD

The purposive sample included: children aged 6 to 18 years who used a PWSD (n=8; diagnoses: cerebral palsy, spinal muscular atrophy, spina bifida, spinal cord injury), parents of children 18 years of age or younger who used a PWSD (n=12), rehabilitation professionals working with children who used a PWSD (n=12), and professionals working at companies manufacturing PWSDs (n=3). Data were gathered via face-to-face interviews conducted either in person or via Zoom^® and analyzed using the constant comparative method.

RESULTS

Three main themes emerged in the data: (1) 'Stand-on-demand' revealed how participants perceived PWSDs as allowing children to stand whenever and wherever they wanted, thereby increasing participation; (2) 'It's more than weight-bearing' uncovered participants' perceptions of psychological and physical benefits from PWSD use; and (3) 'Ecosystems influencing PWSD acquisition and use' revealed child- and non-child-related factors perceived as influencing children's procurement and use of a PWSD.

INTERPRETATION

Use of a PWSD was perceived as providing a unique opportunity for children to stand whenever and wherever they desired. Findings suggest the possible transdiagnostic application of PWSDs. What this paper adds The ability to stand when desired was unique to powered wheelchair standing device (PWSD) use. Participants perceived numerous psychological and physical benefits from PWSD use. Child- and non-child-related factors influenced procurement and use of a PWSD.

Identification of bacteria-derived HLA-bound peptides in melanoma

A variety of species of bacteria are known to colonize human tumours1-11, proliferate within them and modulate immune function, which ultimately affects the survival of patients with cancer and their responses to treatment12-14. However, it is not known whether antigens derived from intracellular bacteria are presented by the human leukocyte antigen class I and II (HLA-I and HLA-II, respectively) molecules of tumour cells, or whether such antigens elicit a tumour-infiltrating T cell immune response. Here we used 16S rRNA gene sequencing and HLA peptidomics to identify a peptide repertoire derived from intracellular bacteria that was presented on HLA-I and HLA-II molecules in melanoma tumours. Our analysis of 17 melanoma metastases (derived from 9 patients) revealed 248 and 35 unique HLA-I and HLA-II peptides, respectively, that were derived from 41 species of bacteria. We identified recurrent bacterial peptides in tumours from different patients, as well as in different tumours from the same patient. Our study reveals that peptides derived from intracellular bacteria can be presented by tumour cells and elicit immune reactivity, and thus provides insight into a mechanism by which bacteria influence activation of the immune system and responses to therapy.

Discovery of IPN60090, a Clinical Stage Selective Glutaminase-1 (GLS-1) Inhibitor with Excellent Pharmacokinetic and Physicochemical Properties

Inhibition of glutaminase-1 (GLS-1) hampers the proliferation of tumor cells reliant on glutamine. Known glutaminase inhibitors have potential limitations, and in vivo exposures are potentially limited due to poor physicochemical properties. We initiated a GLS-1 inhibitor discovery program focused on optimizing physicochemical and pharmacokinetic properties, and have developed a new selective inhibitor, compound 27 (IPN60090), which is currently in phase 1 clinical trials. Compound 27 attains high oral exposures in preclinical species, with strong in vivo target engagement, and should robustly inhibit glutaminase in humans.

Estimating survival in advanced cancer: a comparison of estimates made by oncologists and patients

PURPOSE

To compare estimates of expected survival time (EST) made by patients with advanced cancer and their oncologists.

METHODS

At enrolment patients recorded their "understanding of how long you may have to live" in best-case, most-likely, and worst-case scenarios. Oncologists estimated survival time for each of their patients as the "median survival of a group of identical patients". We hypothesized that oncologists' estimates of EST would be unbiased (~ 50% longer or shorter than the observed survival time [OST]), imprecise (< 33% within 0.67 to 1.33 times OST), associated with OST, and more accurate than patients' estimates of their own survival.

RESULTS

Twenty-six oncologists estimated EST for 179 patients. The median estimate of EST was 6.0 months, and the median OST was 6.2 months. Oncologists' estimates were unbiased (56% longer than OST), imprecise (27% within 0.67 to 1.33 times OST), and significantly associated with OST (HR 0.88, 95% CI 0.82 to 0.93, p < 0.01). Only 41 patients (23%) provided a numerical estimate of their survival with 107 patients (60%) responding "I don't know". The median estimate by patients for their most-likely scenario was 12 months. Patient estimates of their most-likely scenario were less precise (17% within 0.67 to 1.33 times OST) and more likely to overestimate survival (85% longer than OST) than oncologist estimates.

CONCLUSION

Oncologists' estimates were unbiased and significantly associated with survival. Most patients with advanced cancer did not know their EST or overestimated their survival time compared to their oncologist, highlighting the need for improved prognosis communication training. Trial registration ACTRN1261300128871.

Abstract C036: Discovery of IACS-13909, an allosteric SHP2 inhibitor that overcomes multiple mechanisms underlying osimertinib resistance

Osimertinib, a third generation EGFR inhibitor, is a front-line therapy for EGFR mutated non-small lung cancer (NSCLC). The long-term effectiveness of osimertinib is limited by acquired resistance. Clinically identified resistance mechanisms include EGFR-dependent mechanisms such as mutations on EGFR that preclude drug binding, and EGFR-independent activation of the MAPK pathway, for instance via activation of alternate RTKs. It has also been noted that frequently a tumor from a single patient harbors more than one resistance mechanism, and the plasticity between the multiple resistance mechanisms will restrict the effectiveness of therapies targeting a single node of the oncogenic signaling network. SHP2 (Src homology 2 domain-containing phosphatase) is a phosphatase that mediates the signaling of multiple RTKs and is required for full activation of the MAPK pathway. Here we report IACS-13909 - a specific and potent allosteric inhibitor of SHP2 - suppresses the signaling of RTK/MAPK pathway. IACS-13909 potently impedes the proliferation of tumors with a broad spectrum of RTKs as the oncogenic driver. Importantly, in NSCLC models with acquired resistance to osimertinib, IACS-13909 administered as a single agent or in combination with osimertinib potently reduces tumor cell proliferation in vitro and in vivo. Together, our findings provide preclinical evidence for using a SHP2 inhibitor as a therapeutic strategy in acquired EGFR inhibitor-resistant NSCLC. Currently, a compound that potently inhibits SHP2 has been selected as the clinical development candidate and is undergoing IND-enabling studies with a projected first-in-human target of early 2020.

Citation Format: Yuting Sun, Brooke A Meyers, Sarah B Johnson, Angela L Harris, Barbara Czako, Jason B Cross, Paul G Leonard, Faika Mseeh, Maria E Di Francesco, Connor A Parker, Qi Wu, Christopher A Bristow, Jason P Burke, Caroline C Carrillo, Christopher L Carroll, Qing Chang, Ningping Feng, Sonal Gera, Gao Guang, Justin Kwang-Lay Huang, Yongying Jiang, Zhijun Kang, Jeffrey J Kovacs, Xiaoyan Ma, Pijus K Mandal, Timothy McAfoos, Robert A Mullinax, Michael D Peoples, Vandhana Ramamoorthy, Sahil Seth, Erika Suzuki, Christopher Conrad Williams, Simon S Yu, Andy M Zuniga, Giulio F Draetta, Joseph R Marszalek, Timothy P Heffernan, Nancy E Kohl, Philip Jones. Discovery of IACS-13909, an allosteric SHP2 inhibitor that overcomes multiple mechanisms underlying osimertinib resistance [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference on Molecular Targets and Cancer Therapeutics; 2019 Oct 26-30; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2019;18(12 Suppl):Abstract nr C036. doi:10.1158/1535-7163.TARG-19-C036

Doxorubicin obliterates mouse ovarian reserve through both primordial follicle atresia and overactivation

Ovarian toxicity and infertility are major side effects of cancer therapy in young female cancer patients. We and others have previously demonstrated that doxorubicin (DOX), one of the most widely used chemotherapeutic chemicals, has a dose-dependent toxicity on growing follicles. However, it is not fully understood if the primordial follicles are the direct or indirect target of DOX. Using both prepubertal and young adult female mouse models, we comprehensively investigated the effect of DOX on all developmental stages of follicles, determined the impact of DOX on primordial follicle survival, activation, and development, as well as compared the impact of age on DOX-induced ovarian toxicity. Twenty-one-day-old CD-1 female mice were intraperitoneally injected with PBS or clinically relevant dose of DOX at 10 mg/kg once. Results indicated that DOX primarily damaged granulosa cells in growing follicles and oocytes in primordial follicles and DOX-induced growing follicle apoptosis was associated with the primordial follicle overactivation. Using the 5-day-old female mice with a more uniform primordial follicle population, our data revealed that DOX also directly promoted primordial follicle death and the DNA damage-TAp63α-C-CASP3 pathway was involved in DOX-induced primordial follicle oocyte apoptosis. Compared to 21-day- and 8-week-old female mice that were treated with the same dose of DOX, the 5-day-old mice had the most severe primordial follicle loss as well as the least degree of primordial follicle overactivation. Taken together, these results demonstrate that DOX obliterates mouse ovarian reserve through both primordial follicle atresia and overactivation and the DOX-induced ovarian toxicity is age dependent.

Female oncofertility attitude and knowledge: a survey of reproductive health professionals in Shanghai, China

AIM

To evaluate the female oncofertility attitude and knowledge of reproductive health professionals in China.

METHODS

An online survey was distributed to reproductive health professionals in Shanghai, China.

RESULTS

Female professionals were more likely to consider that cancer patients would want to preserve their fertility. Participants with higher educational background tended to have a more positive attitude toward oncofertility. The majority of the participants (71.0%) obtained a fair or low level of oncofertility knowledge, and only 25.3% of them received scores at the 'good knowledge' level.

CONCLUSION

There are significant gaps in the current oncofertility knowledge among reproductive health professionals in China, suggesting an urgent, unmet need for establishing an interdisciplinary fertility preservation training and service system.

Abstract LB-124: Promoting an anti-tumor immune environment with a novel, exquisitely selective CSF1R inhibitor

Tumor-associated macrophages (TAMs) are critical drivers of tumor progression and immunosuppression within the tumor microenvironment. The dominant TAM phenotype is broadly characterized as harboring M2-like macrophage properties, which are anti-inflammatory and pro-tumor, as opposed to M1-like macrophages, which possess tumoricidal and pro-inflammatory characteristics. The dependence of M2 TAMs on CSF1 receptor (CSF1R) kinase signaling has made CSF1R a desirable therapeutic target, and the need for highly selective therapies for use in combinations. Through an extensive medicinal chemistry campaign, we identified a series of orally bioavailable, highly potent, exquisitely selective inhibitors of CSF1R (IC50 &lt; 10 nM) with excellent pharmacologic properties that are appropriate for evaluation as a cancer therapy. The aim of our study was to assess the biological impact of our lead CSF1R inhibitor (CSF1Ri) on macrophage populations and the consequent effect on T effector cells. In vitro biochemical activity was evaluated in various kinase assays comparing our CSF1Ri to BLZ945. The compound was evaluated using syngeneic murine models of colorectal cancer (MC38) and pancreatic adenocarcinoma (PANC02). Tumors were immune profiled using NanoString, immunohistochemistry and flow cytometric analysis establishing that there was a depletion of macrophages and a reduction in the relative amount of M2+ (CD206+MHCII-) cells, with a concomitant increase in M1+ (MHCII+CD206-) cells. Myeloid-derived suppressor cells (MDSCs), CD4, and CD8 cell infiltration were also altered with an elevation of cytotoxic immune cells. In conclusion, we have identified and characterized a novel potent and selective inhibitor of CSF1R with highly favorable PK/PD properties, that compares favorably to BLZ945. We also have clear evidence that our novel CSF1R inhibitors modulates TAM infiltration and phenotype altering the immune cell milieu toward a more favorable anti-tumor environment.

Citation Format: Erika Suzuki, Jeffrey J. Kovacs, Nakia D. Spencer, Sonal Sonal, Ningping Feng, Angela L. Harris, Robert A. Mullinax, Andy M. Zuniga, Sarah B. Johnson, Mikhila Mahendra, Tin Oo Khor, Faika Mseeh, Zhen Liu, Jason P. Burke, Keith Mikule, Martin Tremblay, Timothy P. Heffernan, Philip Jones, Barbara Czako, Joseph R. Marszalek. Promoting an anti-tumor immune environment with a novel, exquisitely selective CSF1R inhibitor [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr LB-124.

Asenapine for the Control of Physical Aggression: A Prospective Naturalist Pilot Study

It has been previously purported that higher relative affinity to the dopamine D4 receptor compared to D2 (i.e., D4/D2 affinity ratio > 1) may underlie unique antiaggression potency. Asenapine is a newer antipsychotic that also has D4/D2 affinity ratio > 1. It has demonstrated efficacy in reducing acute agitation in a placebo-controlled study. We performed a prospective naturalistic, pilot, proof of concept study on an inpatient psychiatric unit. Among patients with aggression at time of admission (≥ 12 on Refined Aggression Questionnaire [RAQ], or ≥ 2 on Modified Overt Aggression Scale [MOAS]), asenapine treatment was associated with a significant reduction in total aggression as measured by the MOAS (-14.7 ± 11.59 vs. -5.4 ± 10.12, P = 0.045), and particularly physical aggression (-8.0 ± 5.06 vs. -0.78 ± 2.40, P < 0.0001) compared to treatment that did not include asenapine. These data suggest that asenapine may be useful in the targeted treatment of aggression, and provide some support for the D4/D2 affinity ratio hypothesis.

Five Reasons to Consider Phytophthora infestans a Reemerging Pathogen

Phytophthora infestans has been a named pathogen for well over 150 years and yet it continues to "emerge", with thousands of articles published each year on it and the late blight disease that it causes. This review explores five attributes of this oomycete pathogen that maintain this constant attention. First, the historical tragedy associated with this disease (Irish potato famine) causes many people to be fascinated with the pathogen. Current technology now enables investigators to answer some questions of historical significance. Second, the devastation caused by the pathogen continues to appear in surprising new locations or with surprising new intensity. Third, populations of P. infestans worldwide are in flux, with changes that have major implications to disease management. Fourth, the genomics revolution has enabled investigators to make tremendous progress in terms of understanding the molecular biology (especially the pathogenicity) of P. infestans. Fifth, there remain many compelling unanswered questions.

Hispanic Americans living in the United States and their risk for obesity, diabetes and kidney disease: Genetic and environmental considerations

The Hispanic American, the largest minority population in the United States, is at increased risk for obesity, diabetes and end-stage renal disease. Here we review genetic and environmental factors that might account for their increased risk for these conditions. Whereas many environmental and genetic factors have important roles in driving the increased risk for obesity and kidney disease in this population, a case is made that excessive intake of sugary beverages is a contributory cause. Studies focusing on decreasing intake of sugary beverages among the Hispanic American could potentially reduce renal and cardiovascular complications in this population.

Analysis of Left Atrial Respiratory and Cardiac Motion for Cardiac Ablation Therapy

Cardiac ablation therapy is often guided by models built from preoperative computed tomography (CT) or magnetic resonance imaging (MRI) scans. One of the challenges in guiding a procedure from a preoperative model is properly synching the preoperative models with cardiac and respiratory motion through computational motion models. In this paper, we describe a methodology for evaluating cardiac and respiratory motion in the left atrium and pulmonary veins of a beating canine heart. Cardiac catheters were used to place metal clips within and near the pulmonary veins and left atrial appendage under fluoroscopic and ultrasound guidance and a contrast-enhanced, 64-slice multidetector CT scan was collected with the clips in place. Each clip was segmented from the CT scan at each of the five phases of the cardiac cycle at both end-inspiration and end-expiration. The centroid of each segmented clip was computed and used to evaluate both cardiac and respiratory motion of the left atrium. A total of three canine studies were completed, with 4 clips analyzed in the first study, 5 clips in the second study, and 2 clips in the third study. Mean respiratory displacement was 0.2±1.8 mm in the medial/lateral direction, 4.7±4.4 mm in the anterior/posterior direction (moving anterior on inspiration), and 9.0±5.0 mm superior/inferior (moving inferior with inspiration). At end inspiration, the mean left atrial cardiac motion at the clip locations was 1.5±1.3 mm in the medial/lateral direction, and 2.1±2.0 mm in the anterior/posterior and 1.3±1.2 mm superior/inferior directions. At end expiration, the mean left atrial cardiac motion at the clip locations was 2.0±1.5 mm in the medial/lateral direction, 3.0±1.8 mm in the anterior/posterior direction, and 1.5±1.5 mm in the superior/inferior directions.

Fat Preference: a novel model of eating behavior in rats

Obesity is a growing problem in the United States of America, with more than a third of the population classified as obese. One factor contributing to this multifactorial disorder is the consumption of a high fat diet, a behavior that has been shown to increase both caloric intake and body fat content. However, the elements regulating preference for high fat food over other foods remain understudied. To overcome this deficit, a model to quickly and easily test changes in the preference for dietary fat was developed. The Fat Preference model presents rats with a series of choices between foods with differing fat content. Like humans, rats have a natural bias toward consuming high fat food, making the rat model ideal for translational studies. Changes in preference can be ascribed to the effect of either genetic differences or pharmacological interventions. This model allows for the exploration of determinates of fat preference and screening pharmacotherapeutic agents that influence acquisition of obesity.

Review of psychiatric services to mentally disordered offenders around the Pacific Rim

This article was commissioned to collate and review forensic psychiatric services provided in a number of key Pacific Rim locations in the hope that it will assist in future dialogue about service development. The Board of the Pacific Rim College of Psychiatrists identified experts in forensic psychiatry from Australia, Canada, China, Hong Kong, Japan, Russia, Singapore, Taiwan, and the US. Each contributor provided an account of issues in their jurisdiction, including mental health services to mentally disordered offenders in prison, competence or fitness to stand trial, legal insanity as a defense at trial, diminished responsibility, and special forensic services available, including forensic hospitals and community forensic mental health services. Responses have been collated and are presented topic by topic and country by country within the body of this review. The availability of mental health screening and psychiatric in-reach or forensic liaison services within prisons differed considerably between countries, as did provisioning of community forensic mental health and rehabilitation services. Diversion of mentally disordered offenders to forensic, state, or hybrid hospitals was common. Legal constructs of criminal responsibility (insanity defense) and fitness to stand trial ("disability") are almost universally recognized, although variably used. Disparities between unmet needs and resourcing available were common themes. The legislative differences between contributing countries with respect to the mental health law and criminal law relating to mentally disordered offenders are relatively subtle. The major differences lie in operationalizing and resourcing forensic services.

Neuromedin U receptor 2 knockdown in the paraventricular nucleus modifies behavioral responses to obesogenic high-fat food and leads to increased body weight

Neuromedin U (NMU) is a highly conserved neuropeptide which regulates food intake and body weight. Transgenic mice lacking NMU are hyperphagic and obese, making NMU a novel target for understanding and treating obesity. Neuromedin U receptor 2 (NMUR2) is a high-affinity receptor for NMU found in discrete regions of the central nervous system, in particular the paraventricular nucleus of the hypothalamus (PVN), where it may be responsible for mediating the anorectic effects of NMU. We hypothesized that selective knock down of NMUR2 in the PVN of rats would increase their sensitivity to the reinforcing properties of food resulting in increased intake and preference for high-fat obesogenic food. To this end, we used viral-mediated RNAi to selectively knock down NMUR2 gene expression in the PVN. In rats fed a standard chow, NMUR2 knockdown produced no significant effect on food intake or body weight. However, when the same rats were fed a high-fat diet (45% fat), they consumed significantly more food, gained more body weight, and had increased feed efficiency relative to controls. Furthermore, NMUR2 knockdown rats demonstrated significantly greater binge-type food consumption of the high-fat diet and showed a greater preference for higher-fat food. These results demonstrate that NMUR2 signaling in the PVN regulates consumption and preference for high-fat foods without disrupting feeding behavior associated with non-obesogenic standard chow.

The 2009 Late Blight Pandemic in the Eastern United States - Causes and Results

The tomato late blight pandemic of 2009 made late blight into a household term in much of the eastern United States. Many home gardeners and many organic producers lost most if not all of their tomato crop, and their experiences were reported in the mainstream press. Some CSAs (Community Supported Agriculture) could not provide tomatoes to their members. In response, many questions emerged: How did it happen? What was unusual about this event compared to previous late blight epidemics? What is the current situation in 2012 and what can be done? It's easiest to answer these questions, and to understand the recent epidemics of late blight, if one knows a bit of the history of the disease and the biology of the causal agent, Phytophthora infestans.

The successful use of cardiopulmonary support for a transected bronchus

A 20-year-old male was involved in a motor vehicle accident and computed tomography revealed a completely transected right mainstem bronchus. An Emergency Department (ED) right anterior thoracotomy was necessary soon after arrival at our institution secondary to acute desaturation that was unresponsive to ventilator and chest tube management. This allowed direct intubation and ventilation of the right middle and lower lobes directly through the thoracotomy incision, which stabilized the patient for transport to the operating room. Once there, percutaneous cardiopulmonary support (CPS) was initiated to allow primary surgical repair of the transected bronchus. Post surgery, the patient was transported to the surgical intensive care unit on CPS which he required for an additional two days. The patient eventually did well and was discharged home. To our knowledge this is the first successful reported case of using the Avalon Elite dual lumen veno-venous cannula for CPS in a patient with complete right main-stem bronchus transection and bilateral pulmonary contusions.

Rubyspira, new genus and two new species of bone-eating deep-sea snails with ancient habits

Rubyspira, a new genus of deep-sea snails (Gastropoda: Abyssochrysoidea) with two living species, derives its nutrition from decomposing whalebones. Molecular phylogenetic and morphological evidence places the new genus in an exclusively deep-sea assemblage that includes several close relatives previously known as fossils associated with Cretaceous cold seeps, plesiosaur bones, and Eocene whalebones. The ability to exploit a variety of marine reducing environments may have contributed to the evolutionary longevity of this gastropod lineage.

Acquisition of dwarf male "harems" by recently settled females of Osedax roseus n. sp. (Siboglinidae; Annelida)

After the deployment of several whale carcasses in Monterey Bay, California, a time-series analysis revealed the presence of a new species of Osedax, a genus of bone-eating siboglinid annelids. That species is described here as Osedax roseus n. sp. It is the fifth species described since the erection of this genus and, like its congeners, uses a ramifying network of "roots" to house symbiotic bacteria. In less than 2 months, Osedax roseus n. sp. colonized the exposed bones of a whale carcass deposited at 1018-m depth, and many of the females were fecund in about 3 months post-deployment. As with other Osedax spp., the females have dwarf males in their tube lumens. The males accrue over time until the sex ratio is markedly male-biased. This pattern of initial female settlement followed by gradual male accumulation is consistent with the hypothesis that male sex may be environmentally determined in Osedax. Of the previously described species in this genus, Osedax roseus n. sp. is most similar to O. rubiplumus, but it has several anatomical differences, as well as much smaller females, dwarf males, and eggs. Osedax roseus n. sp. is markedly divergent (minimally 16.6%) for mitochondrial cytochrome oxidase subunit I (mtCOI) sequences from any other Osedax species.

Association of K121Q polymorphism in ENPP1 (PC-1) with BMI in Caucasian and African-American adults

OBJECTIVE

To test for association of the ectonucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1) K121Q polymorphism with body mass index (BMI) and diabetes in a large sample of Caucasians and African-Americans by selectively genotyping individuals at the extremes of the phenotypic distribution.

SUBJECTS

Subsets comprising the extremes of the BMI distribution (10th-20th and above the 90th BMI percentile for Caucasians and between the 10th-30th and above the 80th percentile for African-Americans) from a group of 10,260 Caucasian and 2268 African-American adults participating in New York Cancer Project were studied.

METHODS

Subjects were genotyped for the ENPP1 K121Q polymorphism by pyrosequencing and tested for association with BMI and diabetes by regression analysis.

RESULTS

Regression analysis with BMI as the dependent variable demonstrated a significant association (P = 0.02) of genotype at K121Q with BMI, with no significant race-by-genotype interaction (P = 0.30). Compared with Q/Q or Q/K individuals, the K/K individuals had a BMI approximately 1.3 kg/m2 higher, without effects of age, gender or race. By logistic regression analysis, the K121Q alleles had no significant effect on diabetes status (P = 0.37) in obese subjects.

CONCLUSION

In both Caucasians and African-Americans, the K121 polymorphism in ENPP1 was associated with increased BMI, but not with diabetes.

Urban youths' perspectives on violence and the necessity of fighting

OBJECTIVES

To assess youth perceptions of the causes and consequences of violence generally, the causes and consequences of fighting specifically, and to determine how best to approach fighting in the context of violence prevention activities.

METHODS

Thirteen structured focus group interviews with youths from three high violence urban settings: a large, urban high school, a training center for disadvantaged youths, and a school for adjudicated youths. Participants were 120 urban, predominately African-American youths and young adults ages 14-22 years (mean: 17.2 years). Seven focus groups were conducted with females, and six with males.

RESULTS

Adolescents identified the causes of violence on multiple levels including: individual, family, interpersonal, and community level factors. Most youths (89%) had been in a physical fight. Participants felt that fighting was not "right", but identified situations in which it was necessary. Specifically, fighting was used as a problem solving tool, and could prevent escalation of violence. Youths felt that the adults in their lives, including physicians, were generally ill equipped to give advice about violence, as adults' experiences were so removed from their own. Participants looked to experienced role models to offer problem solving and harm reduction strategies. Youths were open to receiving anticipatory guidance about violence and fighting from primary care physicians they felt comfortable with, and who showed respect for their experiences.

CONCLUSIONS

Interventions that include blanket admonitions against fighting should be reassessed in light of youth perceptions that fighting plays a complex role in both inciting and preventing more serious violence.

Unintentional and undetermined firearm related deaths: a preventable death analysis for three safety devices

OBJECTIVE

To determine the proportion of unintentional and undetermined firearm related deaths preventable by three safety devices: personalization devices, loaded chamber indicators (LCIs), and magazine safeties. A personalized gun will operate only for an authorized user, a LCI indicates when the gun contains ammunition, and a magazine safety prevents the gun from firing when the ammunition magazine is removed.

DESIGN

Information about all unintentional and undetermined firearm deaths from 1991-98 was obtained from the Office of the Chief Medical Examiner for Maryland, and from the Wisconsin Firearm Injury Reporting System for Milwaukee. Data regarding the victim, shooter, weapon, and circumstances were abstracted. Coding rules to classify each death as preventable, possibly preventable, or not preventable by each of the three safety devices were also applied.

RESULTS

There were a total of 117 firearm related deaths in our sample, 95 (81%) involving handguns. Forty three deaths (37%) were classified as preventable by a personalized gun, 23 (20%) by a LCI, and five (4%) by a magazine safety. Overall, 52 deaths (44%) were preventable by at least one safety device. Deaths involving children 0-17 (relative risk (RR) 3.3, 95% confidence interval (CI) 2.1 to 5.1) and handguns (RR 8.1, 95% CI 1.2 to 53.5) were more likely to be preventable. Projecting the findings to the entire United States, an estimated 442 deaths might have been prevented in 2000 had all guns been equipped with these safety devices.

CONCLUSION

Incorporating safety devices into firearms is an important injury intervention, with the potential to save hundreds of lives each year.

First Report of Potato mop-top virus on Potato from the United States

Potato mop-top virus (PMTV) is a tripartite pomovirus vectored by the powdery scab plasmodiophoromycete Spongospora subterranea pv. subterranea (1). PMTV occurs on potato (Solanum tuberosum) in Europe, the Andes, Asia, and Canada. Internal necrotic arc and fleck tuber symptoms ("spraing") may reduce commercial acceptance of some cultivars (3). PMTV symptoms were discovered in 'Shepody' tubers at the Aroostook Research Farm, Presque Isle, ME in May 2002 and subsequently in 'Russet Burbank' tubers in commercial storage from the 2001 Maine crop. Symptomatic tubers exhibited single or multiple concentric necrotic arcs that were partial or complete, but exhibited no distinct external symptoms. The presence of PMTV in eight 'Shepody' tubers was indicated by positive enzyme-linked immunosorbent assay (ELISA; Adgen, Ltd., Auchincruive, Ayr, Scotland) and confirmed by reverse transcription polymerase chain reaction (RT-PCR). 'Russet Burbank' potatoes were visually diagnosed, and the corresponding halves of 128 symptomatic tubers were forwarded to the University of Maine and APHIS (Beltsville, MD). Of these, ELISA readings in Maine were strongly positive (>3 × background) for 88, ambiguous (1.5-3 × background) for 13, and negative for 27. Subsamples from these three categories were positive by PCR in 17 of 17, 9 of 9, and 12 of 14 cases, respectively. A similar rating, positive or ambiguous, in ELISA testing was identical for all but one case at Beltsville. Confirmation of PMTV required PCR testing, resulting in a characteristic PCR product of 401 bp that was generated from the coat protein coding region on RNA 2 (2) using the primer pair PMTV 1 5'-GCAGCCGTCGAGAATAGATA-3' (RNA nucleotides 316-335) and PMTV 4 5'-GCGAGTTGATGTGCC ACATT-3' (complementary to RNA 2 nucleotides 716-697). An immunocapture RT-PCR using this primer set and the coating antibody from the Adgen ELISA kit was also successful in detecting PMTV. In separate reactions, a second product of 646 bp was generated from the triple gene block on RNA 3 (4) using the primer pair PMTV 5 5'-GGTGAACACGAGGACAAGGT-3' (RNA 3 nucleotides 1417-1436) and PMTV 7 5'-AACAGTCCGGTCTTGTGAAC-3' (complementary to RNA 3 nucleotides 2063-2044). The sequence of these products was 98 to 100% identical to PMTV published sequences. The discovery of this virus will result in adjustments to U.S. and Canadian seed potato certification standards and symptom characterization for common North American cultivars. References: (1) R. A. C. Jones and B. D. Harrison. Ann. Appl. Biol 63:1, 1969. (2) S. Kashiwazak et al. Virology 206:701, 1995. (3) M. Sandgren et al. Am. J. Potato Res. 79:205, 2002. (4) K. P. Scott et al. J. Gen. Virol.75:3561, 1994.

Maternal feeding practices and beliefs and their relationships to overweight in early childhood

To better explore possible factors that may lead to childhood obesity, we developed and analyzed two new instruments that assess maternal feeding practices and beliefs. The Infant Feeding Questionnaire (IFQ) assesses feeding during the entire first year of life and was administered to 453 mothers of children 11 to 23 months old. The Preschooler Feeding Questionnaire (PFQ) assesses feeding of young children between the ages of 2 to 5 years and was administered to 634 mothers of children this age. Each questionnaire was factor analyzed and mean factor scores were calculated and linked with the children's measured and mothers' self-reported weight and height. Mean factor scores from the IFQ and PFQ were compared between mothers who were obese (body mass index > or = 30 kg/m2) and those who were nonobese, between those who did and those who did not have an overweight child (weight-for-height > or = 90th percentile), and between those who had a low income (< or = 185% of the poverty level) and those who had a high income. To control for confounding variables and to detect interaction among variables, hierarchical linear regression was used. Results from this study did not suggest that there is a particular "feeding style" that is associated with overweight in young children; however, there were differences found in feeding behaviors between high and low income mothers.

Amplified effects of d,l-sotalol in canine dilated cardiomyopathy

Despite the presence of well-described cardiac repolarization abnormalities in heart failure, d,l-sotalol effects on cardiac repolarization have not been evaluated in animal models of CHF. The authors hypothesized that the d,l-sotalol effects on cardiac repolarization are altered in canine dilated cardiomyopathy when compared to controls. Effects of d,l-sotalol were compared in seven dogs with tachycardia induced cardiomyopathy (CHF) and six control animals. In an open-chest model, contact monophasic action potential recordings were obtained from RV and LV endocardium/epicardium during and after two doses of d,l-sotalol (1 mg/kg and 3 mg/kg, each over 20 minutes). Effects of d,l-sotalol on action potential duration at 90% repolarization (APD90) were examined at pacing cycle lengths of 300-1,000 ms. Plasma d,l-sotalol levels were measured at baseline, 10, and 40 minutes following each dose. Prolongation of APD90 by d,l-sotalol, was significantly exaggerated in CHF animals versus controls (P < 0.05, ANOVA). These differences were magnified at slow heart rates (P < 0.05, ANOVA). There were no significant differences in plasma d,l-sotalol levels between the two groups. Effects of d,l-sotalol on cardiac repolarization are exaggerated in CHF without significant alterations in plasma drug levels. While using d,l-sotalol in heart failure, independent additional effects due to ventricular electrical remodeling may be a consideration.

Thymoma: update for the new millennium

Thymomas are relatively common tumors of the anterior superior mediastinum. They are usually relatively slowly growing tumors and their prognosis depends on the macroscopic and microscopic invasion of surrounding tissues. Surgery is the mainstay treatment of thymomas, and complete resection represents one of the most important prognostic factors in this disease. Other important prognostic indicators include the tumor stage and size and the presence of symptoms. Postoperative radiotherapy is indicated in tumors with invasion of surrounding tissues, even if resection was radical, since it improves local control and survival. Cytotoxic chemotherapy has been employed in several relatively small phase II studies and in advanced disease has been demonstrated to produce a 50%-80% objective response rate. Neoadjuvant cytotoxic chemotherapy and/or external beam radiotherapy has been used with some success in patients with tumors which are not readily resectable. Novel antiproliferative systemic agents, with both cytotoxic and cytostatic mechanisms of action, are being tested in ongoing prospective clinical trials.

Clinical testing results and high patient satisfaction with a new needle-free device for growth hormone in young children

Fifty children ages 4-10 yr with type 1 diabetes mellitus volunteered to participate in a study to evaluate and compare a new needle-free device developed for growth hormone delivery. Children answered descriptive questions related to nervousness and worry, hurt or pain, redness or bleeding, and stinging and wetness. Choices for answers for each of these five questions were none, a little, or a lot. None or a little was also combined to give a minimal category. Children also answered four questions that compared the needle-free device to their morning insulin needle injection in reference to ease of use, pain, nervousness, and overall preference. Half the children had single comfort rings inserted to increase the injection pressure. Results indicated no difference in question responses with or without pressure rings. Pain (92%), erythema (96%), worry (90%), stinging (86%) and wetness (96%) were minimal and significant (0.001 > p < 0.03) following all questions. Results of the comparative questionnaire indicated that the device was easier (p < 0.03) to use than needles and significantly preferred (p < 0.001) in 74% of children under age 10.

Accessing heterogeneous sources of evidence to answer clinical questions

The large and rapidly growing number of information sources relevant to health care, and the increasing amounts of new evidence produced by researchers, are improving the access of professionals and students to valuable information. However, seeking and filtering useful, valid information can be still very difficult. An online information system that conducts searches based on individual patient data can have a beneficial influence on the particular patient's outcome and educate the healthcare worker. In this paper, we describe the underlying model for a system that aims to facilitate the search for evidence based on clinicians' needs. This paper reviews studies of information needs of clinicians, describes principles of information retrieval, and examines the role that standardized terminologies can play in the integration between a clinical system and literature resources, as well as in the information retrieval process. The paper also describes a model for a digital library system that supports the integration of clinical systems with online information sources, making use of information available in the electronic medical record to enhance searches and information retrieval. The model builds on several different, previously developed techniques to identify information themes that are relevant to specific clinical data. Using a framework of evidence-based practice, the system generates well-structured questions with the intent of enhancing information retrieval. We believe that by helping clinicians to pose well-structured clinical queries and including in them relevant information from individual patients' medical records, we can enhance information retrieval and thus can improve patient-care.

Psychological response to prenatal genetic counseling and amniocentesis

The purpose of the present study was to characterize the psychological status (attitudes toward selective abortion, perceived risk, comprehension, patient satisfaction, coping, and state anxiety) of pregnant women at increased risk for fetal genetic anomalies who were referred for prenatal genetic counseling and amniocentesis; to determine which of these factors would predict amniocentesis use; and to identify patient outcomes associated with counseling and testing. Participants were 129 women aged 18 years and older who had one or more fetal genetic risk factors. All were recruited from an urban women's health clinic. The results revealed elevated perceptions of risk and moderate state anxiety despite adequate comprehension of, and patient satisfaction with, the process and content of genetic counseling. Approximately 78% agreed to testing; those who consented were more likely to hold favorable attitudes toward abortion than those who refused. Post-counseling, women experienced decrease in their perceived risk of having a baby born with a birth defect although perceived risk estimates remained higher than actual risks. Anxiety was clinically elevated and highest at the pre-counseling stage, though it dissipated to normal levels over time. Previous experience with prenatal diagnostic testing, increased perceived risk of a birth anomaly, and favorable attitudes toward abortion were independently associated with increased pre-counseling anxiety. Women who were more anxious pre-counseling remained more anxious post-counseling. Coping (high versus low monitoring) was unrelated to anxiety. These findings suggest that women who participate in prenatal counseling and testing may be subject to experience distress and unrealistic perceptions of their risk and may benefit from interventions designed to lessen these states.

Disordered eating, body mass, and glycemic control in adolescents with type 1 diabetes

OBJECTIVE

To examine the relationship between disordered eating attitudes and behaviors, BMI, and glycemic control in adolescents with type 1 diabetes.

RESEARCH DESIGN AND METHODS

In a cross-sectional design, 152 adolescents (ages 11-19 years) completed three scales from the Eating Disorders Inventory (EDI): Body Dissatisfaction, Drive for Thinness, and Bulimia. All subjects had diabetes for > 1 year. Glycemic control was assessed by glycosylated hemoglobin (HbA1c). Height and weight were measured to assess BMI.

RESULTS

Adolescents with type 1 diabetes did not report more disordered eating attitudes and behaviors than the normative comparison sample. Male subjects with type 1 diabetes reported fewer symptoms of bulimia and female subjects with type 1 diabetes reported greater body satisfaction than the normative group. A higher BMI was a significant predictor of greater body dissatisfaction, more so for female than male subjects. Symptoms of bulimia were associated with older adolescence and female sex. Those with more symptoms of bulimia were also more likely to have a higher BMI. Sex (female) and body dissatisfaction (more dissatisfied) predicted a stronger desire to be thin. Longer duration of disease, more symptoms of bulimia, and obesity all predicted poorer glycemic control.

CONCLUSIONS

Female patients aged 13-14 years seem to be at greatest risk for developing disordered eating patterns. Using the clinical cutoff score (> or = 5) of the EDI Bulimia subscale as a screener in diabetes clinics may help identify adolescents whose disordered eating patterns are likely to compromise their glycemic control.

Screening programs to identify children at risk for diabetes mellitus: psychological impact on children and parents

Screening programs to identify persons atrisk for diabetes mellitus (DM), before disease onset, are considered essential to understanding the natural history of the disease and for prevention program development. However, screening programs are complicated by imprecise markers of disease risk, the absence of a known effective prevention method, the use of children, and a wide variety of psychological, social, and educational challenges. Research relevant to four issues is presented: (1) parent and child anxiety in response to at-risk notification as well as how participants cope with this news; (2) accuracy of mothers' understanding of their babies' risk status; (3) predictors of participant recruitment and retention in longitudinal studies of this type; and (4) protocol compliance in prevention trials for type 1 DM. Integration of behavioral research into screening and prevention trials would help address the ethical concerns raised by such trials and improve their scientific quality.

Altered response to ibutilide in a heart failure model

OBJECTIVE

Despite the frequent use of anti-arrhythmic drugs in the general population, the electrophysiologic effects of these agents have not been elucidated in congestive heart failure (CHF).

METHODS

To examine the impact of left ventricular dysfunction on actions of type III anti-arrhythmic drugs, we evaluated the actions of ibutilide in a canine model of pacing-induced dilated cardiomyopathy. Following ablation of the atrioventricular node, effects on action potential duration at 90% (APD(90)) were compared in vivo, between eight CHF animals and seven controls. Monophasic action potential recordings were obtained from right and left ventricular endocardium/epicardium during and after three doses of ibutilide (0. 01, 0.02 and 0.05 mg/kg), at pacing cycle lengths of 300-1000 ms.

RESULTS

APD(90) prolongation with ibutilide (0.01 mg/kg) was significantly greater in CHF vs. controls (P=0.0026, ANOVA). However, plasma ibutilide levels at this dose, were not significantly different between the two groups. In CHF, maximal effects were observed at the lowest dose, whereas effects were gradual and dose-dependent in controls. With ibutilide administration (0.01 mg/kg), an increased dispersion of left-right ventricular APD(90) was observed in CHF, but not in controls (P=0.03). A trend was observed, for increased incidence of non-sustained polymorphic ventricular tachycardia in CHF.

CONCLUSIONS

In the presence of CHF, the actions of ibutilide are altered significantly. These findings may reflect altered tissue effects, as a consequence of myocardial electrical remodeling in CHF.

Comparing syntactic complexity in medical and non-medical corpora

With the growing use of Natural Language Processing (NLP) techniques as solutions in Medical Informatics, the need to quickly and efficiently create the knowledge structures used by these systems has grown concurrently. Automatic discovery of a lexicon for use by an NLP system through machine learning will require information about the syntax of medical language. Understanding the syntactic differences between medical and non-medical corpora may allow more efficient acquisition of a lexicon. Three experiments designed to quantify the syntactic differences in medical and non-medical corpora were conducted. The results show that the syntax of medical language shows less variation than non-medical language and is likely simpler. The differences were great enough to question the applicability of general language tools on medical language. These differences may reduce the difficulty of some free text machine learning problems by capitalizing on the simpler nature of narrative medical syntax.

Using narrative reports to support a digital library

The vast amount of information collected and stored in clinical systems can be a significant challenge in the integration of digital libraries and electronic medical records, especially the selection of clinical data to be used in the search, retrieval, and summarization processes. In this study, we describe the use of information retrieval measures with natural language processor output to identify critical information in narrative reports. Our hypothesis is that clinical data that occur often in narrative reports are less important to clinicians than findings that occur rarely. We used the information retrieval methods to analyze one year of discharge summaries. We then conducted a performance study, using physicians as subject. Results show that the methods can be used for filtering critical information from reports. Further studies need to be done on evaluation of the method based on an evaluation of the system performance in the context of a digital library.

Early life stress and disease among offspring and siblings of individuals with type 1 diabetes mellitus

Major life events, recent life stressors, and childhood diseases were examined among children and adolescents who were offspring, siblings, or other relatives of persons with type 1 diabetes mellitus (DM). All youth were recruited as part of a multi-site nationwide trial on the prevention of type 1 DM; parents of 347 children (4 to 18 yr) completed measures that asked about children's life events, recent stressors, and childhood illnesses. Analyses compared age groups (young child, preadolescent, adolescent) and relative type (offspring, sibling, other relative). Findings revealed offspring and siblings did not differ from "other relatives" in terms of life events, recent life stress, and disease/illness variables. However, siblings were reported to have fewer major life events and fewer life stressors in the past 12 months than offspring; siblings also had fewer infectious diseases during the first two years of life compared to offspring. Few age-related differences were found. Overall, results suggest that offspring and siblings of persons with type 1 DM are not at a disadvantage in terms of early life stress or disease in comparison to youth who have other family members with diabetes. However, siblings may have some advantages relative to children who are offspring. The mechanisms underlying these relationships require further elucidation and study.